内科消化系统胰腺炎acute pancreatitis

1、History What other points of the history do you want to know? Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms Consider the FollowingHistory, J.H. No significant past medical or surgical his

2、tory No medications No allergies to medications Smokes 1ppd x 40 yrs, and drinks ethanol heavily. He denies drug use. Family history was noncontributory.Differential DiagnosisBased on History and Presentation Cholecystitis Choledocholithiasis PUD Gastritis Pancreatitis Bowel obstruction Mesenteric i

3、schemia Gastroenteritis Appendicitis Hepatitis Diabetes Rectus hematoma Pneumonia Pyelonephritis Trauma w/ duodenal hematoma. Physical Examination What would you look for on physical examination?Physical Examination, J.H. Vital Signs: T 38.5 BP 120/70 P 100 R18 Appearance: lying still in moderate di

4、stress. Not jaundiced and sclera were anicteric. His mucous membranes were dry. Resp: His lungs were clear to auscultation. CV: heart was regular and without murmurs, rubs, or gallops.Physical Examination, J.H. Abdomen: soft, moderately distended, tender in the mid-epigastric region and right upper

5、quadrant. No palpable masses. Bowel sounds were positive. Extremities: without cyanosis, clubbing, or edema. Rectal exam: no masses, guaiac neg.Would you like to revise your Differential Diagnosis?Revised Differential Cholecystitis PUD Pancreatitis Bowel obstruction Mesenteric ischemia Gastroenterit

6、is Hepatitis Rectus hematoma PneumoniaLaboratory What would you obtain?LabsConsider the following CBC, Electrolytes, LFTs, CMP, LDH, Amylase, Lipase, PT, PTT, Urinalysis, ABG, Lab Results, J.H.Lab Results, DiscussionThis patient has a hypokalemic hypochloremic metabolic alkalosis from vomiting.He ha

7、s an elevated amylase and lipase consistent with pancreatitis.On admission he has 4 out of 5 of Ransons criteria and can be expected to e very sick.There are 6 more of Ransons criteria that should be tracked over the next 48 hours.Can you list Ransons criteria?Ransons Early Objective Prognostic Sign

8、s that Correlate with the Risk of Major Complications or DeathOn Admission Non-biliary BiliaryAge 55 70WBC 16 18Glucose 200 220LDH 350 400SGOT 250 250Ransons Early Objective Prognostic Signs that Correlate with the Risk of Major Complications or DeathDuring the Initial 48 Hours Non-biliary BiliaryHe

9、matocrit decrease 10% 10%BUN increase 5 mg/dL 2 mg/dLCalcium 8 mg/dL 8 mg/dLArterial Po2 4 mEq/L 5 mEq/LFluid sequestration 6 L 4 L Ransons Early Objective Prognostic Signs that Correlate with the Risk of Major Complications or DeathNote 1. The amylase and lipase levels are not prognostic signs and

10、do not relate to the severity of the attack or prognosis.2. LDH must usually be specifically ordered. It is not included with most comprehensive metabolic panels or with most liver function tests.Interventions at this point? IVF LR Bolus 1-2 liters then LR at 150cc/hr titrate to urine output/volume status NPO Foley catheter NG Tube Admission to ICU His initial CT Scan is shown below: Repeat CT Scan is shown belowWhat do you see?Supportive TreatmentElective Cholecystectomy if caused by gallstones.